How (and why) prescription drugs end up on the street

I feel compelled to comment on the recent surge of attention paid to the issue of prescription medication abuse. Being a potential provider of said prescription medications, I deem it helpful and necessary to provide my view from the trenches, the locations from which prescriptions originate, with the hope of bettering our communal understanding of the problem at hand.

A great deal of attention is paid to the assignment of blame. The fault for the epidemic, it seems, must lie with an individual — the doctor, the dealer, the addict, the government. In fact, this is a systemic and layered problem. Let’s address the key players.

BLAME THE DOCTORS

It’s logical to blame the doctors - we write the prescriptions. Without a prescription, the medications are not made available for abuse. I readily admit that some of us are to blame for this societal pox.

Some of us are a little too loose with our pens.

I’ve seen patients in my office who were clearly coming in just for pills to abuse or sell. When I call their previous doctors for some insight, I would hear various sorry excises (the quotes are paraphrased, and the doctors shall remain nameless):

“I’m an older guy with a family, I don’t want to get beat up.

“Well, if they have an MRI, I just give them the pills.”

“Well, I’m retiring soon anyway.”

“I can’t give you information over the phone — confidentiality laws, you know.”

Some of us would rather treat than diagnose.

In our busy community, the average general practice physician works with volume. Hundreds of patients cycle through the average office weekly, affording the physician minimal time to interact with each one. If someone says they have back pain, it’s easier for some doctors to just prescribe a narcotic and move a little closer to emptying the waiting room.

Some of us want money.

A good number of abusers have health insurance, and they present themselve reliably every 30 days for a fresh supply of pills. That allure of guaranteed money every month is tempting for some.

BLAME THE DEALERS

This is obvious. The dealers get the prescriptions from the doctors and channel them out to the public. But how are they able to prosper?

Some dealers are really good actors.

Pain is a subjective experience, and some dealers can be quite convincing in their complaints of pain. A patient who reports severe pain, who can mimic the appropriate physical examination findings, who has an MRI that shows some degree of pathology, and who has been treated by other physicians previously is difficult to discount.

Some dealers are really good shoppers.

There are a lot of doctors out there. By paying cash for their visits, and by using multiple pharmacies, dealers can string along countless doctors all of whom think they’re the only one treating this poor hapless soul.

Our community is blind to their existence.

Really, a seventeen year old driving an AMG S-class Mercedes with chrome rims and tinted windows shouldn’t arouse some degree of suspicion?

BLAME THE ADDICTS

These are the people who take the pills. These are the people we read about in the newspaper — they rob homes, they cause accidents, they get arrested, they die.

Some addicts are not recognized.

This is a tough one, because some people are truly addicted to prescription medications through no fault of their own. People have surgery, or are in car accidents, or have work related injuries, and have real pain. They are prescribed painkillers and eventually become hooked. These people must not be punished nor ignored; these people need help. They must be recognized and offered assistance in a detoxification program.

Some addicts are not really addicts.

We can’t give everyone the benefit of the doubt. Some people are just chasing the high.

Some addicts have precedence.

I’ve discovered addicts in my practice who were parents, and even grandparents. I’ve removed people in their 50s and 60s from my practice for medication abuse. What’s to stop a youngster from abusing pills if grandpa’s doing it?

BLAME THE GOVERNMENT

It’s easy to blame the government. When something goes wrong in society, it’s the fault of the government.

The government is slow to detect and respond.

The DEA does have a system in place for monitoring prescriptions to assure that people are not obtaining multiple prescriptions each month. However, the system as it exists today is prohibitively slow. I’ve removed people from my practice long before I received notice from the DEA that they might have ulterior motives.

The government makes it difficult.

HIPAA (Health Insurance Portability and Accountability Act) confidentiality laws suggest that I might get in trouble should I call another doctor or pharmacy to obtain information about a patient without written consent. So how am I supposed to take action when a potential dealer or addict is sitting in my office asking for medications? How can I prevent pills from getting out to the street without risking my own career in the process?

SO WHAT’S THE ANSWER?

Doctors need to be made free to communicate with each other in the moment to perform medical background checks on potential dealers and addicts. Doctors need to be motivated to make the calls, putting their credibility over their nonchalance. We need to recognize and report the dealers in our neighborhood — those neighbors of ours who sit in their garages all night entertaining visitors, those teenagers who drive expensive cars and wear expensive clothes and jewelry, and those unemployed individuals who seem strangely able to afford expensive homes and vacations. We must help the helpless, identifying those of us who are truly addicted and getting them the help they deserve. The government must establish the means whereby potential abusers can be investigated and identified at the point of care, at the moment of presentation, so not a single pill ends up on the street.---

ABOUT DR. GIANNONE

Dr. Dean F. Giannone, M.D. left his hometown of Hewlett, New York to pursue a Bachelor of Science degree in Biology-Psychology at Tufts University. After graduating, he completed his medical school training at SUNY Health Science Center at Brooklyn. After medical school, he completed a residency program in Internal Medicine at Staten Island University Hospital.

He opened his Internal Medicine practice in Eltingville in the summer of 2001. He has been board certified in Internal Medicine since 1999.

He maintains membership in the American Medical Association and the American College of Physicians.